PEM Pearls: 2017 AAP Section of EM’s Guide to Pediatric Community Acquired Pneumonia

Pediatric community-acquired pneumonia (CAP) is an acute, common, and potentially serious infection of the pulmonary parenchyma in children. In November 2010, the American Academy of Pediatrics endorsed “The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.” [PDF]¹ Based on this guideline, the American Academy of Pediatrics (AAP) Section on Emergency Medicine’s Committee on Quality Transformation developed a clinical algorithm for CAP in the ED setting.

CAP Definition

The definition of CAP is complicated by lack of gold standard as clinical and radiographic findings may be discordant. This algorithm applies to generally healthy children 3 months-18 years of age in whom the clinician has diagnosed uncomplicated CAP by clinical or imaging findings, addressing the following evaluation and management decisions:

1. Assessment of severity of illness (mild, moderate, or severe)

Management decisions for CAP are dictated by the clinical status of the patient based on oxygenation (pulse oximetry reading), work of breathing, hydration/perfusion status, and appearance (well, ill, or toxic).

2. Diagnostic tests

Blood tests (counts and cultures), imaging, and viral testing (CDC recommendations) are based on severity of illness. Patients with mild CAP do not routinely need testing and can be managed clinically. A chest x-ray (CXR) assists in management decisions for moderate/severe CAP; a chest ultrasound can be used as an adjunct diagnostic tool.

3. Management

Antimicrobial therapy is targeted at the likely organism, patient’s age, history of exposure, possibility of resistance, and severity of illness. Alternatives and therapeutic options for penicillin allergy, specific etiologies, suspicion for atypical pneumonia, and antivirals for influenza (CDC recommendations) are noted as footnotes.

1. Mild Presentation: The vast majority of mild CAP can be treated outpatient with oral antibiotics using high-dose amoxicillin as a first-line agent. Discharge criteria include reliable follow-up and the ability to tolerate oral fluids.
2. Moderate/Severe Presentation (with no or small pleural effusion): Admission to hospital for parenteral antibiotics is recommended. Moderately ill patients can be treated with narrow-spectrum agents such as ampicillin while severely ill patients should receive 3^rd generation cephalosporins. Children who are toxic-appearing may also require staph coverage and/or resuscitation and respiratory support.
3. Moderate to large pleural effusions on CXR are indicative of complicated pneumonia are outside the scope of this algorithm.

This algorithm is for use in the ED at the bedside. It is not meant to be a comprehensive guideline on CAP.

AAP Section on EM’s Committee CAP Algorithm (2017)

Based on the IDSA/PIDS guideline, this easy-to-use, 1-page algorithm is designed to help clinicians make evidence-based decisions at the bedside for evaluation and management of CAP in the ED setting. It includes guidance on severity assessment, testing (blood tests, imaging, and viral tests), as well as treatment (antibiotic choices and disposition decisions).

Author panel for AAP Section on EM’s algorithm: Shabnam Jain, MD, MPH, FAAP; Katherine Mandeville, MD; Anne Stack, MD; Andrea Morrison, MD, MS; Scott A. Barron, MD; Paul C. Mullan, MD, MPH; Michael DiStefano, MD; Mark Neuman, MD, MPH; Susan Duffy, MD; Joseph Zorc, MD; Todd Florin, MD MSCE

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